You are also welcome to read about our therapists and include their name under “Anything Else” on this web intake form.

Schedule An Appointment

To schedule an appointment, this form MUST be filled out completely. You will receive a confirmation from our intake coordinator.

Appointment Intake Form

Name: (As spelled on insurance card) (Required)

Email: (Required)

Phone: (Required)

Brief description of why you are seeking therapy:

I am interested in: IndividualCoupleMedication

Days and times you are regularly available:
Appointments after 5:00 PM fill up quickly, so it is best to include a few choices.
You will increase your chance of a quicker appointment with more flexibility. Rasi Associates is not open for business on Saturday or Sunday.

Insurance Company: Please see insurance we accept above.

Insurance ID Number:

Date of Birth:

Behavioral Health or Provider Phone Number: found on back of insurance card